rowder ollege appliation

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PROGRAM COST: Please visit hps://www.crowder.edu/financial-aid/tuion- residency/ for the latest tuion and fees. *The purchase of items such as uniforms, housing, fuel, transportaon, patches, stethoscopes, shears, and other personal equipment and accessories is the finan- cial responsibility of the student. NON-DISCRIMINATION POLICY: Crowder College is an equal opportunity/affirmative action/educational/employment institution, and is nondiscriminatory relative to race, religion, color, national origin, sex, age, and qualified disability. Crowder College is committed to providing educational opportunities to all qualified students regardless of their economic or social status and will not discrimi- nate on the basis of handicaps, race, color, sex, creed, or national origin. The Vice President of Student Affairs, Farber B uilding, and Human Resources Director, Newton Hall, coordinate efforts to comply with the provisions of Title VI of the Civil rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973. APPLICATION PACKET INCLUDES: Student Application Employment Form Personal Health History Form Physical Examination Form CROWDER COLLEGE APPLICATION STUDENT ELIGIBILITY To be eligible for the RN to PARAMEDIC program, you need to meet the following minimum requirements: Read at minimal college level Be adaptable to stressful situations EMT certification/license highly recommended Show a positive appearance, motivation and attitude (in the clinical and field internship seg- ments, the student will be working closely with patients, nurses, physicians and EMS person- nel and must maintain a high degree of professionalism) AHA BLS and ACLS Provider within good standing, and Registered Nurse (RN) license must be in good standing with 1000 hours of RN work experience in the last 2 years. Proof of negative 10-panel drug screen Proof of negative criminal background check and ONE of the following: Two or more years of Emergency/Critical Care (ICU, CVICU, CCU, etc.) experience OR; One year of RN experience (ER/Critical Care) with a current EMT license and one year of pre-hospital experience OR; One year of RN experience with current CFRN, CCRN, CEN or CTRN certification that is within good standing, and is actively working in emergency/critical care KRISTIN SPENCER MS, NRP EMS Educaon Program Director 417-455-5505 l [email protected] IKE ISENHOWER MHA, NRP Allied Health Division Chair I EMS Instructor 417.455.5643 I [email protected] KYLE RITTER MBA, CFRN, RN, FP-C, NRP EMS Instructor 417.455.5416 I [email protected] hps://www.crowder.edu/academics/departments/allied-health/ paramedic/ BUILDING A CIVIL, SERVING, LITERATE, LEARNING PRIOR TO ENROLLMENT: 1. Apply to become a Crowder student through Admissions (may apply online) 2. Submit to the Records Office: High School Diploma/GED transcript Any and all college transcripts Drivers License or Photo ID 3. Submit completed RN to PARAMEDIC application packet INCLUDE THE FOLLOWING IN YOUR APPLICATION PACKET: State EMT License (or country of origin equivalent) Current American Heart Association Basic Life Support for Healthcare Providers (CPR) card. (CPR certification must be maintained current throughout the PARAMEDIC training). ACLS provider Drivers License Hepatitis B: Proof of 1st inoculation of series prior to start of class; or if series is complete, proof of all inoculation dates; or proof of Titer date and results. Immunization Record Verification of TB skin test and negative reading Proof of RN Licensure not currently subject to disciplinary action COVID vaccination highly recommended Head shot photo (275-Non-EMS Qualified only); may be sent either electronically or paper copy with application Results of 10-panel drug screen Results of criminal backgound check

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Please visit https://www.crowder.edu/financial-aid/tuition- residency/ for the latest tuition and fees. *The purchase of items such as uniforms, housing, fuel, transportation, patches, stethoscopes, shears, and other personal equipment and accessories is the finan- cial responsibility of the student.
NON-DISCRIMINATION POLICY: Crowder College is an equal opportunity/affirmative action/educational/employment institution, and is nondiscriminatory relative to race, religion, color, national origin, sex, age, and qualified disability. Crowder College is committed to providing educational opportunities to all qualified students regardless of their economic or social status and will not discrimi- nate on the basis of handicaps, race, color, sex, creed, or national origin. The Vice President of Student Affairs, Farber Building, and Human Resources Director, Newton Hall, coordinate efforts to comply with the provisions of Title VI of the Civil rights Act of 1964, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973.
APPLICATION PACKET INCLUDES:
Form • Physical Examination Form
STUDENT ELIGIBILITY
To be eligible for the RN to PARAMEDIC program, you need to meet the following minimum requirements:
• Read at minimal college level • Be adaptable to stressful situations • EMT certification/license highly recommended • Show a positive appearance, motivation and attitude (in the clinical and field internship seg-
ments, the student will be working closely with patients, nurses, physicians and EMS person- nel and must maintain a high degree of professionalism)
• AHA BLS and ACLS Provider within good standing, and Registered Nurse (RN) license must be in good standing with 1000 hours of RN work experience in the last 2 years.
• Proof of negative 10-panel drug screen • Proof of negative criminal background check
and ONE of the following:
• Two or more years of Emergency/Critical Care (ICU, CVICU, CCU, etc.) experience OR; • One year of RN experience (ER/Critical Care) with a current EMT license and one year of pre-hospital experience OR; • One year of RN experience with current CFRN, CCRN, CEN or CTRN certification that is within good standing, and is actively working
in emergency/critical care
417-455-5505 l [email protected]
IKE ISENHOWER MHA, NRP Allied Health Division Chair I EMS Instructor 417.455.5643 I [email protected]
KYLE RITTER MBA, CFRN, RN, FP-C, NRP EMS Instructor
417.455.5416 I [email protected]
PRIOR TO ENROLLMENT:
1. Apply to become a Crowder student through Admissions (may apply online) 2. Submit to the Records Office:
• High School Diploma/GED transcript • Any and all college transcripts • Driver’s License or Photo ID
3. Submit completed RN to PARAMEDIC application packet
INCLUDE THE FOLLOWING IN YOUR APPLICATION PACKET:
• State EMT License (or country of origin equivalent) • Current American Heart Association Basic Life Support for Healthcare
Providers (CPR) card. (CPR certification must be maintained current throughout the PARAMEDIC training).
• ACLS provider • Driver’s License • Hepatitis B: Proof of 1st inoculation of series prior to start of class; or
if series is complete, proof of all inoculation dates; or proof of Titer date and results.
• Immunization Record • Verification of TB skin test and negative reading • Proof of RN Licensure not currently subject to disciplinary action • COVID vaccination highly recommended • Head shot photo (275-Non-EMS Qualified only); may be sent either
electronically or paper copy with application • Results of 10-panel drug screen • Results of criminal backgound check
Student Name: Date: / /
Social Security Number (last 4 digits): _______ Email address: ___________________________________
Emergency contact _______________________________________________________________________ Name Relationship Phone
Education: High School/GED: _____________________________________ Graduation Date: __________
Address: ______________________________________________________________________
Please describe any previous health/medical work experience:
Have you ever applied or been enrolled in an Paramedic Program? Yes No
NOTICE: Please indicate by signing below, that you have read and understand the following statement: “A National Background report prior to student clinical practice is required by the Crowder College EMS program.”
Have you ever been convicted of a felony? Yes No
If Yes is checked, please explain:
Yes, I have read and understand the program information and statement above. The information I have given in this application is cor- rect, to the best of my knowledge.
Signature: _________________________________________________ Date: __________________
Heart disease Migraine
Hypertension Frequent Headaches
Tuberculosis Emotional/Nervous disorder
If you checked any of the above, please explain:
Have you ever been treated for a back ailment or injury? Yes No
If you marked yes, please explain:
Are you currently taking any medications? Yes No
If yes, please list the medications you are currently taking:
PERSONAL HEALTH HISTORY
Name (Please Print):
Student Signature (do not print): Date:
EMERGENCY SERVICES SECTION 190.165
In compliance with the Missouri Revised Statutes, Chapter 190 of the Emergency Services Section 190.165, each applicant will be re- quired to answer the following questions and others at the time of application to take the licensure examination:
Have you ever been finally adjudicated and found guilty, or entered a plea of nolo contendere in a criminal prosecu- tion under the laws of any state or of the United States, whether or not you received a suspended imposition of sen- tence for any criminal offense? ______________
Have any administrative licensure actions ever been taken against your EMT license in Missouri or any other state? ____________
IF ANY OF THESE QUESTIONS ARE ANSWERED YES, THE MISSOURI BUREAU OF EMS WILL RULE WHETHER OR NOT THE APPLI- CANT MAY RECEIVE A LICENSE AFTER COMPLETION OF THE PARAMEDIC PROGRAM.
I have given true, accurate and complete information on this application to the best of my knowledge. I hereby authorize inves- tigation of all statements and understand that omissions or misrepresentation of facts may jeopardize my position as a candi- date for admission or be cause for dismissal if I am accepted as a student.
Current Employer _______________________________________Position Held ___________________
Employer ______________________________________________ Position Held __________________
EMPLOYMENT
How did you hear about the Crowder College PARAMEDIC Program?
What are your plans after graduation from the PARAMEDIC Program?
List any awards, honors, citations or positions held in school or community organizations, athletic endeavors, continuing education and any other special recognitions you have received during the past five (5) years:
ATTESTATION
I attest that all the information on the application is accurate and complete to the best of my knowledge. I also understand that falsification of any part of the Paramedic Program application will result in denial/removal from the paramedic pro- gram and is not subject to appeal.
Yes No Signature ____________________________________Date ______________
Student’s Name (Print) _________________________________ Date: ________
TO BE COMPLETED BY A PHYSICIAN , PA or RNP. ALL AREAS MUST BE COMPLETED BEFORE FINAL ACCEPTANCE INTO THE PROGRAM
Temperature: ______ Pulse: ______ Blood Pressure: _______ Respiration: _____
Height: ____ ft. ____ in. Weight: ______ lbs.
Vision: Right ________ Left ________ Corrected: Right _______ Left ______
Hearing: Right ________ Left _________
__ Hepatitis B Vaccine record __Measles, Mumps & Rubella __Varicella __Tetanus
__Influenza
Yes
Is this individual in suitable health for EMS training?
No Yes Is this individual capable of performing the PARAMEDIC technical standards? (see back)
Comments/Recommendations:
Address: __________________________________________________________________________
• Assist in lifting and carrying injured and/or ill persons to and from the ambulance.
• Engage in pushing and/or pulling to assist in extrication of a patient pinned beneath or inside a vehicle, and in ve-
hicles with electrical hazards.
• Walk, stand, lift, carry, and balance in excess of 150 pounds without assistance, (250 pounds with assistance)
while lifting, pulling, pushing and carrying a patient.
• Stoop, kneel, bend, crouch and crawl on uneven terrain to gain access to a patient.
• Climb stairs, hillsides, and ladders to gain access to a patient.
• Work effectively in low light, confined spaces, extreme environmental conditions and other dangerous environ- ments while remaining calm.
• Perform fine motor movements while in stressful situations and under time constraints.
• Perform major motor movements as required to operate the ambulance stretcher, and equipment.
PARAMEDIC TECHNICAL STANDARDS A student must be able to perform the following job analysis tasks:
PLEASE TAKE TO PHYSICIAN WITH PHYSICAL EXAMINATION FORM
CHECKLIST
• Have you applied to Crowder College? • Have you requested all high school and college transcripts be forwarded to the
Records Department? • Provided results from 10-panel drug screen and background check? • Made photocopies of: 1)driver's license, 2) immunization records including Hepatitis
B, proof of negative TB, and seasonal flu shot, 3) head shot photo for I.D. badges, all certifications and 4)RN license?
• Completed the work verification form and skill set questionnaire?
*Every candidate will be evaluated and ranked using a predetermined rubric. Application to program does not guarantee admission.
601 Laclede Ave | Neosho MO 64850 | www.crowder.edu Neosho Cassville Nevada Webb City McDonald County
Crowder College...building a civil, serving, literate, learning community of responsible citizens.
Name of Applicant/Student: _____________________________________________________
EMTP 275 Clinical Experience Waiver Form
The completion of this form acknowledges that the above-named student is using their work
experience in the pre-hospital environment (minimum 250 documented work hours) to replace clinical
experience normally required for the Crowder College RN to Paramedic EMS Qualified program.
For this form to be validated, the following criteria must be met for completion and the
documentation must be on file with the college.
1. The student can perform the skills listed below within their current job duties or, the skills
are/were within their scope of practice within the last 5 years (please initial each skill you are
currently qualified to use):
Crowder College...building a civil, serving, literate, learning community of responsible citizens.
2. The student currently works, or within the last 5 years, has worked in pre-hospital care
(ground or air ambulance) at least 250 hours in one of the following capacities listed below:
a. A flight RN that works for an air medical service with a flight paramedic or flight RT
that is an equal provider of care or a decision maker in clinical care.
b. An RN that works on an ambulance and provides advanced life support (ALS) care
for patients being transported.
By signing this form, I attest that the aforementioned student meets the criteria to accept the clinical
waiver in accordance with Crowder College, MO BEMS, and CoAEMSP guidelines.
Printed Name of Verifying Individual: _____________________________________________
Signature of Verifying Individual: ________________________________________________
Title of Verifying Individual: ____________________________________________________